COVID-19-associated cardiac arrest: Difference between revisions
Jump to navigation
Jump to search
| Line 302: | Line 302: | ||
==Prevention== | ==Prevention== | ||
* | *.Effective measures for the primary prevention of ventricular arrhythmia during using hydroxychloroquine in long QT syndrome or aquired LQTS or heart rate<50/min or recieving azithromycin,redmisivir, lopinavir, ritonavir include EKG and QTc measurement.'''PMID: 32244059''' | ||
* | ** If QTc ≥500 ms, consult with cardiologist. | ||
** If QTc<500ms, start hydroxychloroquine and repeat EKG after 1-3 days. | |||
** After starting first dose of hydroxychloroquine, If QTc≥500mse, increased QTc>60ms, or ventricular ectopy were observed , repeat EKG after 4 hours. | |||
** avoidance of hypokalemia and treatment of diarrhea 2.Effective measures for the primary prevention of ventricular arrhythmia in brugada syndrom is startind acetaminophen or parastamol immediately if there is sign of fever and self isolation | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
Revision as of 04:54, 19 July 2020
|
COVID-19 Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
COVID-19-associated cardiac arrest On the Web |
|
American Roentgen Ray Society Images of COVID-19-associated cardiac arrest |
|
Risk calculators and risk factors for COVID-19-associated cardiac arrest |
For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayesha Javid, MBBS[2]
Overview
The sudden cardiac death is defined as the death that occurs within one hour of onset of symptoms in witnessed cases and within 24 hours of last being seen alive when it is unwitnessed. Out-of-hospital cardiac arrest means cessation of cardiac mechanical activity that occurs outside of the hospital setting and is confirmed by the absence of signs of circulation. According to a study done in China, About 12% of patients with COVID-19 experienced cardiac arrest in the absence of previous history of cardiac disease.
Historical Perspective
- In December 2019, the COVID-19 outbreak first appeared in China, Wuhan.[1]
- On February 20, 2020, the first case of COVID-19 was documented in Lodi Province of Italy.[2]
- In April 2020, An increase in out of hospital cardiac arrest was reported during the COVID-19 pandemic.
- In January 2020, the first COVID-19 case was documented in the United States.[3]
Classification
Cardiac arrest associated covid19 may be classified into three subtypes:
1.Pulseless electerical activity
2. bradyarrhythmia and asystolic arrest
3.letal tachyarrhythmia
Pathophysiology
- The pathogenesis of cardiac arrest associated covid-19 is characterized by cytokine storm, especially elevation of IL-6 doi: 10.1038/s41577-018-0098-z
- IL-6 directely blocks hERG/Kv11.1 potassium channels and causes APD prolongation and ventricular repolarization.
- IL-6 induces hyperactivity of cardiac sympathetic nerve.doi: 10.1093/eurheartj/ehw208MedlineGoogle Sch
- IL-6 inhibits cytochrome P450 enzyme involved in matobolism of some QTc prolongation drugs.doi: 10.1016/j.jacc.2020.03.031
- Hydroxychloroquine and lopinavir/ritonavir inhibit hERG-K+ channel and induce both ventriculat repolarization and the level of other QT prolongation drugsdoi: 10.1016/j.jacc.2020.03.031
- Hydroxychloroquine inhibit CYP2D6 (cytochrome P450 2D6) ,then the level of antipsychotics,antidepressants and antihistamins increase.doi: 10.1016/j.jacc.2020.03.031
- Ritonavir inhibits CYP3A4 (cytochrome P450 3A4), then the level of azols antifungals, macrolides (particulary azithromycin),antidepressants,antihistamines,fluoroquinolones increase.doi: 10.1016/j.jacc.2020.03.031
- intrinsic genetic susceptibility (ie, p.Ser1103Tyr-SCN5A) in african americans covid-19 patients has been associated with increased risk of torsade points arrhythmia PMID: 32359771
Drug induced[4]
- Since the COVID-19 pandemic, several pharmacological therapies have been proposed, one of them is of two anti-malarial and antirheumatic drugs called Chloroquine or Hydroxychloroquine.
- Due to their cost-effectiveness and easy availability, there is a surge in the use of Chloroquine and Hydroxychloroquine, with or without Azithromycin. The clinical trials in order to estimate their efficacy are still in the preliminary stage, however, a notable concern is of their cardiac adverse effects.
- This includes QT prolongation and Torsade de pointes (TdP) leading to sudden cardiac death.
- The risk is there when these drugs are prescribed separately, however it increases several folds when these drugs are administered together, especially in patients with underlying hepatic disease or renal failure.
Genetic susceptibility:
- Epidemiological studies have shown that African Americans have higher COVID-19 associated morbidity and mortality as compared to people from other ethnic groups.
- Recent studies show that this ethnic predilection is due to the genetic factors which contribute to a common ion channel variant p.Ser1103Tyr-SCN5A which confer an increased risk of drug-induced long QT syndrome (DI-LQTS) and drug-induced sudden cardiac death (DI-SCD).
- p.Ser1103Tyr-SCN5A generates late or persistent sodium current which is further aggravated by hypoxia or respiratory acidosis secondary to lungs involvement in COVID-19.
- This has and has been linked to an increased risk of ventricular arrhythmia (VA) such as torsade de pointes and sudden cardiac death (SCD) in African Americans.
Causes
he causes of ventricular tachyarrhythmia and sudden cardiac death in covid-19 are caracterized by:PMID: 32380288
1.Environmental risk factors include:
- covid-19 directed QTc prolongation drugs( hydroxychloroquin ± azithromycin and lupinavir/ritonavir)
- Concurrent use of QT prolongation drug (anti -emetics,floroquinolones,SSRIs)
- Electrolitise abnormalities(hypokelemia and hypomagnesemia)
2. Internistics risk factors includes:
- High risk comorbidity condition(CHF,CKD,DM,COPD)
- Ages≥65,male gender
- inherited arrhythmia syndromes
3. Other mechanisms include:
- hypoxia causes ventricular arrhythmia and sudden cardiac death by myocardial injuries and increased in late I /NA
- exaggerated immune response ( IL-6 increased the proportion of action potential duration/ QTc)
- increased sympathetic activity
- inhition of CYP450
- direct myocardial injury(SARS-COV-2 myocarditis
COVID-19 associated cardiac arrest may occur due to the following causes:[5]
- Cardiac
- Respiratory
- Others
Clinical Features[edit | edit sourc
Differentiating [disease name] from other Diseases[edit | edit source]
- differentiation diagnosis of inherited cardiac arrest in covid19 patients include:
| Inherited causes of cardiac arrest and malignant arrhythmia associated covid-19 | long QT syndrome | BRUGADA syndrome | short QT syndrome | cathecolaminergic polymorphic ventricular tachaycardia |
|---|---|---|---|---|
| mechanism of arrhythmia | mutation in KCNQ1, KCNH2, and SCN5A)
block potassium current and prolongation of ventricular repolarization induces EAD and PMID: 16412861 |
PMID: 27423412
loss of function in SCN5A in %30 of patients |
mutation in potassium channel genes KCNH2, KCNQ1, and KCNJ2 and SLC4A3 | mutation in RYR2
PMID: 23390049 |
| ekg | QTc>450ms in men
QTc>470ms in women PMID: 20642543 |
coved-type ST-segment elevation
and T-wave inversion in lead V1 and/or V2) |
QTc<360 msec |
| risk factors related to covid-19 | using ≥ one drugs inducing prolongation of QT interval in the setting of covid-19
1.using hydroxychloquine and chloroquine 2. using CYP3a4 inhibitore that increases hydroxychloroquine level include;lupinavir,ritonavir . azithromycin 3. hydroxychloquine does not resultPMID: 17646028 significant prolonged QT in cases without LQTS 3. fever:PMID: 18551196 causes QT prolongation and cardiac arrest in Long QTS type2 in the setting of septic shock in covid-19.
|
1.fever may increased PR interval, QRS width, and the maximum J point in patients with BrSPMID: 18678856
2. fever increases the risk of cardiac arrest in BrS 3. Risk of life threatening arrythmia in BrS related to fever was (65%)higher in young patients less than 5 year old (%65)PMID: 29649615 and %25 in patients older than 70 year old |
1.There is no risk of arrhythmia when patients affected by covid19. |
2.fever is not the risk factor of arrhythmia |
| symptomes | torsade de pointes and fatal ventricular arrhythmia | ventricular fibrilation and sudden cardiac death | syncope,ventricular fibrillation, sudden cardiac death | ventricular arrhythmia during exercise and stress related to covid-19 |
| management | 1.controlling the fever with parastamol
2.ECG monitoring untill resolving type1 brugada pattern 3. self isolation |
2. hydroxychloroquine may prolonge QTinterval and useful in treatment of SQTS type 1 (KCNH2-related) and type 3 (KCNJ2 related PMID: 30441573 | 1.do not use epinephrine in the setting of ventricular arrhythmia
2. flecainide is treatment of choice without any interaction with lopinavir, ritonavir and chloroquine. |
Epidemiology and Demographics
Incidence
- There is a two-times rise in the incidence of Out of hospital Sudden cardiac arrest (OHCA) during the COVID-19 pandemic as compared to the non-pandemic time period.
- According to a study done in China, about 12% of patients with COVID-19 without a history of heart problems experience cardiac arrest during their hospitalization.[6]
- In a study done among 761 Chinese patients with severe COVID-19, about 20% patients developed in-hospital cardiac arrest within 40 days of their hospitalization course.[5]
Mortality
- There is a significant increase in the mortality rate of the OHCA patients.[7]
Age
- Mean age 69.7 years is observed among patients who experienced Out of hospital Sudden cardiac arrest (OHCA) .[7] .
Gender
- Studies show that males have a slightly higher incidence of Out of hospital Sudden cardiac arrest (OHCA) as compared to the females.[7]
Race
A higher incidence is seen among African-Americans as compared to the Caucasians.[8]
Risk Factors
- Common risk factors in the development of arrhythmia and cardiac arrest in covid-19 are :PMID: 32244059
- fever
- stress
- electrolytis disrturbances
- use of viral drugs
Screening
- To view screening for COVID-19, click here.
Natural History, Complications, and Prognosis
- The proportion of patients developed out of hospital cardiac arrest (OHCA) increased during covid-19 pandemic.DOI: 10.1056/NEJMp2008017
- common causes of OHCA durig covid-19 pandemic include:acu 1.acute cardiac events ( coronary syndrome, heart failure,arrhythmia,) 2.http://dx.doi.org/10.1016/j.thromres.2020.04.013 thromboembolic events related to covid19 (pulmonary embolism, acute coronary syndrome)3.acute respiratory distress and hypoxia related to covid19 4. late presentation for example acute MI in hospital due to lockdown and movement restriction 4. overwelming of medical service 5. myocarditis
5. letal arrhythmia by using azithromycin and https://doi.org/10.1016/S0140-6736(20)31180-6 6.myocardial injury and myocarditis
- Prognosis of patients with severe covid 19 pneumonia with in hospital cardiac arrest (IHCA) was poor in wohan .PMID: 32283117
- mortality rate of patients with COVID-19 is approximately 1-2%PMID: 32109013
- Prognosis of patients with severe covid 19 pneumonia with in hospital cardiac arrest (IHCA) was poor in wohan .PMID: 32283117
Diagnosis
Diagnostic Study of Choice
- To view the study of choice for diagnosis of COVID-19, click here.
History and Symptoms
- To view the history and symptoms of COVID-19, click here.
Physical Examination
- To view the complete physical examination in COVID-19, click here.
Laboratory Finding
- To view the laboratory findings on COVID-19, click here.
Electrocardiogram
- A patient experiencing sudden cardiac death can have ventricular fibrillation associated ECG changes such as ventricular tachycardia with irregular rhythm and indiscernible P waves or QRS complexes.
- Heart block.[9]
- Pulseless electrical activity.[9]
- Other abnormal ECG findings include QT prolongation. ECG shows corrected QT interval (QTc) more than 500 ms..
- Asystole.[9] [10]
X-ray
- There are no typical x-ray findings for cardiac arrest due to COVID-19.
- To view the x-ray finidings on COVID-19, click here.
Echocardiography or Ultrasound
- There are no typical echocardiographic findings for cardiac arrest due to COVID-19.
- To view the echocardiographic findings on COVID-19, click here.
CT scan
- There are no typical CT scan findings for cardiac arrest due to COVID-19.
- To view the CT scan findings on COVID-19, click here.
MRI
- There are no typical MRI findings for cardiac arrest due to COVID-19.
- To view the MRI findings on COVID-19, click here.
Other Imaging Findings
- There are no other imaging findings for cardiac arrest due to COVID-19.
- To view other imaging findings on COVID-19, click here.
Other Diagnostic Studies
- To view other diagnostic studies for COVID-19, click here.
Treatment
- Cardiopulmonary resuscitation
- Immediate basic life support or advanced cardiac life support with an automatic external defibrillator is essential to safe the life of the patient. If the COVID-19 infection was confirmed, the EMS personnel is instructed to wear personal protective equipment (PPE) before performing cardiopulmonary resuscitation.
- Implantable Cardioverter Defibrillator (ICD)
- An Implantable cardioverter defibrillator (ICD) is the preferred therapeutic modality in most survivors of sudden cardiac death. This device does not prevent the recurrence of arrhythmia, instead, it terminates them in case if they do recur.
- Pharmacologic therapy in survivors of sudden cardiac arrest
- Antiarrhythmic drugs: Amiodarone is the most effective for preventing recurrent ventricular tachyarrhythmias. It is recommended to immediately give Amiodarone following an event of sudden cardiac arrest in patients with recurrent ventricular tachyarrhythmias as well as for those who have refused Implantable Cardioverter Defibrillator (ICD).
- Beta blocker:It is recommended that almost all patients who survive an episode of sudden cardiac arrest should receive a beta-blocker as part of their therapy in combination with an antiarrhythmic drug, particularly in those patients who have survived sudden cardiac death due to ventricular tachycardia or ventricular fibrillation. Beta-blockers has shown to reduce the future incidence of sudden cardiac death.
Prevention
- .Effective measures for the primary prevention of ventricular arrhythmia during using hydroxychloroquine in long QT syndrome or aquired LQTS or heart rate<50/min or recieving azithromycin,redmisivir, lopinavir, ritonavir include EKG and QTc measurement.PMID: 32244059
- If QTc ≥500 ms, consult with cardiologist.
- If QTc<500ms, start hydroxychloroquine and repeat EKG after 1-3 days.
- After starting first dose of hydroxychloroquine, If QTc≥500mse, increased QTc>60ms, or ventricular ectopy were observed , repeat EKG after 4 hours.
- avoidance of hypokalemia and treatment of diarrhea 2.Effective measures for the primary prevention of ventricular arrhythmia in brugada syndrom is startind acetaminophen or parastamol immediately if there is sign of fever and self isolation
References
- ↑ Liu, Yen-Chin; Kuo, Rei-Lin; Shih, Shin-Ru (2020). "COVID-19: The first documented coronavirus pandemic in history". Biomedical Journal. doi:10.1016/j.bj.2020.04.007. ISSN 2319-4170.
- ↑ Baldi, Enrico; Sechi, Giuseppe M.; Mare, Claudio; Canevari, Fabrizio; Brancaglione, Antonella; Primi, Roberto; Klersy, Catherine; Palo, Alessandra; Contri, Enrico; Ronchi, Vincenza; Beretta, Giorgio; Reali, Francesca; Parogni, Pierpaolo; Facchin, Fabio; Bua, Davide; Rizzi, Ugo; Bussi, Daniele; Ruggeri, Simone; Oltrona Visconti, Luigi; Savastano, Simone (2020). "Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy". New England Journal of Medicine. doi:10.1056/NEJMc2010418. ISSN 0028-4793.
- ↑ Sayre, Michael R.; Barnard, Leslie M.; Counts, Catherine R.; Drucker, Christopher J.; Kudenchuk, Peter J.; Rea, Thomas D.; Eisenberg, Mickey S. (2020). "Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR". Circulation. doi:10.1161/CIRCULATIONAHA.120.048951. ISSN 0009-7322.
- ↑ Giudicessi, John R.; Noseworthy, Peter A.; Friedman, Paul A.; Ackerman, Michael J. (2020). "Urgent Guidance for Navigating and Circumventing the QTc-Prolonging and Torsadogenic Potential of Possible Pharmacotherapies for Coronavirus Disease 19 (COVID-19)". Mayo Clinic Proceedings. 95 (6): 1213–1221. doi:10.1016/j.mayocp.2020.03.024. ISSN 0025-6196.
- ↑ 5.0 5.1 Shao, Fei; Xu, Shuang; Ma, Xuedi; Xu, Zhouming; Lyu, Jiayou; Ng, Michael; Cui, Hao; Yu, Changxiao; Zhang, Qing; Sun, Peng; Tang, Ziren (2020). "In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China". Resuscitation. 151: 18–23. doi:10.1016/j.resuscitation.2020.04.005. ISSN 0300-9572.
- ↑ Zheng, Ying-Ying; Ma, Yi-Tong; Zhang, Jin-Ying; Xie, Xiang (2020). "COVID-19 and the cardiovascular system". Nature Reviews Cardiology. 17 (5): 259–260. doi:10.1038/s41569-020-0360-5. ISSN 1759-5002.
- ↑ 7.0 7.1 7.2 Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C; et al. (2020). "Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study". Lancet Public Health. doi:10.1016/S2468-2667(20)30117-1. PMC 7255168 Check
|pmc=value (help). PMID 32473113 PMID: 32473113 Check|pmid=value (help). - ↑ Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ (2020). "Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans". Heart Rhythm. doi:10.1016/j.hrthm.2020.04.045. PMC 7198426 Check
|pmc=value (help). PMID 32380288 PMID: 32380288 Check|pmid=value (help). - ↑ 9.0 9.1 9.2 Srinivasan NT, Schilling RJ (2018). "Sudden Cardiac Death and Arrhythmias". Arrhythm Electrophysiol Rev. 7 (2): 111–117. doi:10.15420/aer.2018:15:2. PMC 6020177. PMID 29967683 PMID: 29967683 Check
|pmid=value (help). - ↑ Parish DC, Goyal H, Dane FC (2018). "Mechanism of death: there's more to it than sudden cardiac arrest". J Thorac Dis. 10 (5): 3081–3087. doi:10.21037/jtd.2018.04.113. PMC 6006107. PMID 29997977 PMID: 29997977 Check
|pmid=value (help).
[[Category:]]